Feasibility of Implementing Lung Cancer Screening Programs

Lung cancer screening programs have been documented to reduce the mortality associated with lung cancer among high-risk patients, but the feasibility of their implementation in a clinical setting has been questioned. A recent investigation tested a small-scale implementation of such program and the results suggest that although it may indeed be effective, the costs and administrative burden may be considerable.

Smoking arguably constitutes the prototypical example of an environmental factor underlying cancer. In fact, risks of developing lung cancer are nearly 20 folds higher among smokers. Implementing Lung Cancer Screening (LCS) programs by means of annual Computed Tomography (CT) scans was proposed as an avenue to reduce lung cancer mortality. In support of this suggestion, results from the National Lung Screening Trial show that LCS programs may decrease lung cancer mortality by three deaths per 1000 high-risk patients. Despite these encouraging data, concerns were raised regarding the practical feasibility of this approach. Moreover, very few studies have addressed this question empirically by implementing a small-scale LCS program end evaluating its costs, effectiveness and pitfalls.

Fortunately, a recent study published in JAMA Internal Medicine sheds light on this matter. In fact, an American group of clinical investigators led by Dr. Linda Kinsinger established an LCS program in eight hospitals affiliated with the Veterans Health Administration (VHA) and collected data from July 2013 to June 2015. This enabled them to evaluate several outcomes related to the practical concerns of this approach, including the proportion of patients who willingly agree to participate and the proportion of positive tests reported, among others. In all hospitals, patients were between 55 to 88 years old, did not have a medical history of cancer and had not undergone a CT scan within the last 12 months. Nurses were in charge of reviewing the smoking history of each patient and only current or former smokers (defined as a minimum of 30 packs-year) were considered for enrollment. The possibility of participating in the LCS program was then introduced to the patient by a healthcare professional.

Among 4246 patients who met these criteria, 2452 (57,7%) agreed to participate and 2106 (85,9%) completed their first CT scan before July 2015. Among them, an impressive number of 1257 patients (59,7%) were diagnosed with lung nodules, which are usually benign masses but can sometimes develop into cancer. Overall, 31 lung cancers were confirmed in those examinations. Furthermore, the authors created a guide to help future efforts aimed towards implementing LCS programs in a clinical setting.

Practically speaking, the authors warn against the administrative burden associated with LCS programs. Despite the fact that VHA hospitals are equipped with an efficient informatics system to track medical records, further optimization was required to collect data related to smoking history as well many other parameters. Moreover, the success of such programs greatly depends on hiring of competent coordinators and the availability of radiological facilities, which have financial and perhaps also medical implications if LCS programs end up impeding on other routinely performed scans. Finally, the authors note that there is considerable variability in the proportion of positive tests reported across the eight sites and suggest this may arise because of a lack of standardization in reading CT scans results. However, it is important to put the results into context as there are many limitations. First, the study was initiated based on medical records and a substantial amount of information was missing in these files, thereby impacting the accuracy of the enrollment process. Second, the study was performed over only one year of follow-up. For these reasons, other longer studies appear necessary to ascertain the feasibility of implementing LCS programs.

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